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           Homeowners /Renters /Manufactured Home (Mobil)/ Flood Insurance Quote Request

        

 

Please fill out as much information as possible.

If you have any questions regarding this form please contact us.

Home Quote Request Form - (Texas Residents Only!)

(* Indicates a required field)

All information provided will be regarded as strictly confidential, and will be used only to secure an accurate quotation for insurance coverage.

First Named Insured:

Additional Named Insured ( Usually Spouse):

 

*Full Name (as shown on your drivers license):

Full Name (as shown on your drivers license)

*SSN #

*DOB:

SSN #

DOB:

        (ie;999-99-9999)

         (MM/DD/YYYY)

       (ie;999-99-9999)

         (MM/DD/YYYY)

*Business/Industry :

*Occupation

If "Other" Occupation Please Describe

*Highest Level of Education

 

 

Business/Industry : Occupation

If "Other" Occupation Please Describe

Highest Level of Education

Email Address:                                                            (For Our  Agency Staff Use Only)

*Email Address :                (For Our  Agency Staff Use Only )

 

Fax #

 

*Send Quick Quote By : Email Fax Both

 

*Contact Phone Numbers:

        Day :   

 

Evening :   

 

        Cell : 

 

Do you currently have Homeowners Insurance? Yes   No   Need help with this question call 1-800-361-8734 !

*If yes, Name of Current Carrier:  

*Policy #  

*Expiration Date:

* Prior Annual Premium * Current Renewal Premium
If yes, how long have you had Homeowners Insurance with your current insurer?
If no current coverage how long has it been since you had homeowners insurance?

Year you purchased home?   Initial Purchase Amount $  

 

Physical Address:        

 *Address:  

*City:

 *State: Zip:

*County :

Mailing Address:       Same as Mailing Address
 Address:
  

City: 

        State :    Zip: 

County:

Coverage Policy Limits Requested :

*Type of Dwelling To Be Insured :  *Requested Effective Date:
*Deductible: *Wind/Hail Deductible:
*Dwelling Coverage $ *Personal Property Coverage $
*Personal Liability Limit $ *Medical Payments Limit $

*Sewer/Drain Back-Up Limit $

*Sudden Accidental Water Discharge/Leakage Damage Limit $
*Replacement Cost Coverage Dwelling             

Personal Property                                        

 

 

Optional Coverages

Most Commonly Requested

 

 

Glass  Mold Scheduled Jewelry $     Scheduled Silverware $  Special Computer $   Collections: Art/Stamps/Guns/Other $              Increased Adjacent Structures $ Ordinance Of Law                    Unscheduled Home Business Property $    Small Outboard Motor Liability $  

Policy Form  Requested :

 

*Please Select The Standard Texas Homeowners Coverage Form(s) You Wish Us To Provide A Quote For  :

 HO-A ( Named Perils Policy Forms - typically offers lower rates in exchange for coverage that only pays when a loss caused by a named perils/risk listed in policy occurs ) ** This Policy Form Generally Offers The Lowest Possible Rates In Exchange For More Limited Coverage.

 HO-B ( Broad Policy Forms - typically offers moderate rates in exchange for coverage broader form  with all risk coverage on dwelling and broad form named perils/risks coverage available for personal property  ) *** This Policy Form Is Our Most Often Selected "Top Choice" By Our Customer As It Offers A Great Value  (Benefits VS Cost) .

HO-C ( All Risk Policy Forms - typically offers higher rates in exchange for the extensive coverage available by providing all perils/risk coverage for losses that occurs which are not specifically excluded perils/risks or otherwise specifically limited within the policy form. ) ** This Policy Form Is Normally Selected By Homeowners With Higher Than Average Valued Homes Who Are Seeking The Most Extensive Homeowners Coverage Available To Protect  Many Of Their Most Valuable Personal Assets " 

All Of The Above ( I wish to compare all three Standard Texas Homeowners Coverage Forms )

 * Do You Want Us To Also Provide You With A Flood Insurance Quote ? Yes 

* Do You Want Us To Also Provide You With A Personal Umbrella Liability Policy ? Yes

Check Here If You Are Requesting Quote For " Renters Personal Property Insurance Policy "

 

Underwriting Information:

*Construction: *Roof: *Roof Age: *Square. Footage:
*Year Built: *Stories: *Garage: *# of Car Stalls:
*Occupancy: *Pool: *Fenced Pool : *Trampoline:
*Pets: (Pets) Breed: *Alarms: *Monitored:
*Fire Hydrant   Feet To 0-100 101-500         501-1000 1000+ *Fire Station Miles  Within 5   5 -10  10+ *Within City Limits Yes   No *Primary Residence Yes No
*Foundation *Rental Property Yes No *Community Entrance Gated or Guarded Yes No Sprinkler System Yes No
*Under Construction Yes No *Live Stock Yes No *Strom Shutters Yes No *Mortgagee Yes No
*Owner Occupied Yes No *Maintenance *Air Conditioning Ducts *Farm Home Yes No
*Fire Place Yes N *Wood Burning Stove Yes N *Central Air Conditioning Heating Yes *Dead Bolt Smoke Alarm Extinguishers Yes No

*Any losses incurred in the last 5 years to the insured's home or personal possessions at this or another location? Yes No

If "Yes" Please Provide Details:

*Has property insurance been cancelled, declined or non-renewed in the last 5 years? Yes No

If "Yes" Please indicate reason property insurance was cancelled, declined or non-renewed?

Is dwelling unoccupied by owner for more than 8 consecutive weeks per year ? Yes No

 

If the home is over 20 years old, please indicate the year updates were completed:

Electrical

Roof

 Plumbing

 Heating

 

Comments/Remarks:

 

Submission of quote request form to Hemphill Insurance Agency does not constitute a binding confirmation of new or revised insurance coverage. 

 To confirm binding or current policy revisions you must receive a written confirmation for any  new or change in coverage from our agency staff.

 

       

 

 

    

 

Is there a Co-Applicant?

Yes No
 
 

Co-Applicant Information


 
 

 
 

 
 

 
 

 
 

 
 

 
 

Spouse Information


 
 

Spouse First Name


 

 
 

Spouse Middle Name


 

 
 

Spouse Last Name


 

 
 

Spouse Social Security Number


 

 
 

Spouse Date of Birth


 

 
 

Spouse Gender

 

Spouse Marital Status

 

Spouse Business/Industry

 

Spouse Occupation

 

Spouse Highest Level of Education

Mailing Address
 
Street Address    
Street Address (Line 2)    
 

ZIP

   
 
 
stateInclude
       
 

City

 
 
 
MailCity
       
 

County

 
 

State

TX
 
 
stateCount
       
ZIP  
 

Additional Auto Policy Information


 
 

Additional Home Policy Information


 
 

Home Policy Form (click for definitions)

 

Is the location address the same as the mailing address?

Yes No
 
 

Location Address


 
 

Time at Present Address - Years


 

 
 

Time at Present Address - Months


 
Personal App: Home Underwriting
 
Mortgagee?
 
Additional Insured
 
Additional Insured Student Living A way from Residence Premises
 
Additional Residences Premises
 
Additional Residence Premises Rented
 
Assisted Living Care Coverage
 
Is the home under construction? Yes No
 
Is there a business on the premises? Yes No
 
 

Business Address


 
Is there a swimming pool? Yes No
 
Is there a dog on the premises? Yes No
 
Is there a woodburning stove on the premises? Yes No
 
Is there a solid fuel appliance (food, coal or pellet) on premises? Yes No
 
Are horses and/or livestock kept on the premises? Yes No
 
Is there a trampoline on the premises Yes No
 
Is residence exclusively held for rental? Yes No
 
Is dwelling owner unoccupied for more than 8 consecutive weeks? Yes No
 
Current or most recent property insurance carrier?
 

Prior Effective Date


 

 
 

Prior Expiration Date


 

 
 

Prior Policy Number


 

 
 

Prior Premium


 

 
Has property insurance been cancelled, declined or non-renewed in the last 5 years? Yes No
 
Any losses incurred in the last 5 years to the insured's home or personal possessions at this or another location? Yes No
 
Does insured qualify for multi-policy credit? Yes No
 
Is this a secondary dwelling? Yes No
 
 

# of People Employed Full Time (Gardener, Housekeeper, Nanny, etc.)?


 

 
Inside City Limits? Yes No
Personal App: Home Underwriting
 
Mortgagee?
 
Additional Insured
 
Additional Insured Student Living A way from Residence Premises
 
Additional Residences Premises
 
Additional Residence Premises Rented
 
Assisted Living Care Coverage
 
Is the home under construction? Yes No
 
Is there a business on the premises? Yes No
 
 

Business Address


 
Is there a swimming pool? Yes No
 
Is there a dog on the premises? Yes No
 
Is there a woodburning stove on the premises? Yes No
 
Is there a solid fuel appliance (food, coal or pellet) on premises? Yes No
 
Are horses and/or livestock kept on the premises? Yes No
 
Is there a trampoline on the premises Yes No
 
Is residence exclusively held for rental? Yes No
 
Is dwelling owner unoccupied for more than 8 consecutive weeks? Yes No
 
Current or most recent property insurance carrier?
 

Carrier Name (if not in list)


 

 
 

Prior Effective Date


 

 
 

Prior Expiration Date


 

 
 

Prior Policy Number


 

 
 

Prior Premium


 

 
Has property insurance been cancelled, declined or non-renewed in the last 5 years? Yes No
 
Any losses incurred in the last 5 years to the insured's home or personal possessions at this or another location? Yes No
 
Does insured qualify for multi-policy credit? Yes No
 
Is this a secondary dwelling? Yes No
 
 

# of People Employed Full Time (Gardener, Housekeeper, Nanny, etc.)?


 

 
Inside City Limits? Yes No
Personal App: Home Underwriting
 
Mortgagee?
 
Additional Insured
 
Additional Insured Student Living A way from Residence Premises
 
Additional Residences Premises
 
Additional Residence Premises Rented
 
Assisted Living Care Coverage
 
Is the home under construction? Yes No
 
Is there a business on the premises? Yes No
 
 

Business Address


 
Is there a swimming pool? Yes No
 
Is there a dog on the premises? Yes No
 
Is there a woodburning stove on the premises? Yes No
 
Is there a solid fuel appliance (food, coal or pellet) on premises? Yes No
 
Are horses and/or livestock kept on the premises? Yes No
 
Is there a trampoline on the premises Yes No
 
Is residence exclusively held for rental? Yes No
 
Is dwelling owner unoccupied for more than 8 consecutive weeks? Yes No
 
Current or most recent property insurance carrier?
 

Carrier Name (if not in list)


 

 
 

Prior Effective Date


 

 
 

Prior Expiration Date


 

 
 

Prior Policy Number


 

 
 

Prior Premium


 

 
Has property insurance been cancelled, declined or non-renewed in the last 5 years? Yes No
 
Any losses incurred in the last 5 years to the insured's home or personal possessions at this or another location? Yes No
 
Does insured qualify for multi-policy credit? Yes No
 
Is this a secondary dwelling? Yes No
 
 

# of People Employed Full Time (Gardener, Housekeeper, Nanny, etc.)?


 

 
Inside City Limits? Yes No
Personal App: Home Underwriting
 
Mortgagee?
 
Additional Insured
 
Additional Insured Student Living A way from Residence Premises
 
Additional Residences Premises
 
Additional Residence Premises Rented
 
Assisted Living Care Coverage
 
Is the home under construction? Yes No
 
Is there a business on the premises? Yes No
 
 

Business Address


 
Is there a swimming pool? Yes No
 
Is there a dog on the premises? Yes No
 
Is there a woodburning stove on the premises? Yes No
 
Is there a solid fuel appliance (food, coal or pellet) on premises? Yes No
 
Are horses and/or livestock kept on the premises? Yes No
 
Is there a trampoline on the premises Yes No
 
Is residence exclusively held for rental? Yes No
 
Is dwelling owner unoccupied for more than 8 consecutive weeks? Yes No
 
Current or most recent property insurance carrier?
 

Carrier Name (if not in list)


 

 
 

Prior Effective Date


 

 
 

Prior Expiration Date


 

 
 

Prior Policy Number


 

 
 

Prior Premium


 

 
Has property insurance been cancelled, declined or non-renewed in the last 5 years? Yes No
 
Any losses incurred in the last 5 years to the insured's home or personal possessions at this or another location? Yes No
 
Does insured qualify for multi-policy credit? Yes No
 
Is this a secondary dwelling? Yes No
 
 

# of People Employed Full Time (Gardener, Housekeeper, Nanny, etc.)?


 

 
Inside City Limits? Yes No
Personal App: Home Underwriting
 
Mortgagee?
 
Additional Insured
 
Additional Insured Student Living A way from Residence Premises
 
Additional Residences Premises
 
Additional Residence Premises Rented
 
Assisted Living Care Coverage
 
Is the home under construction? Yes No
 
Is there a business on the premises? Yes No
 
 

Business Address


 
Is there a swimming pool? Yes No
 
Is there a dog on the premises? Yes No
 
Is there a woodburning stove on the premises? Yes No
 
Is there a solid fuel appliance (food, coal or pellet) on premises? Yes No
 
Are horses and/or livestock kept on the premises? Yes No
 
Is there a trampoline on the premises Yes No
 
Is residence exclusively held for rental? Yes No
 
Is dwelling owner unoccupied for more than 8 consecutive weeks? Yes No
 
Current or most recent property insurance carrier?
 

Carrier Name (if not in list)


 

 
 

Prior Effective Date


 

 
 

Prior Expiration Date


 

 
 

Prior Policy Number


 

 
 

Prior Premium


 

 
Has property insurance been cancelled, declined or non-renewed in the last 5 years? Yes No
 
Any losses incurred in the last 5 years to the insured's home or personal possessions at this or another location? Yes No
 
Does insured qualify for multi-policy credit? Yes No
 
Is this a secondary dwelling? Yes No
 
 

# of People Employed Full Time (Gardener, Housekeeper, Nanny, etc.)?


 

 
Inside City Limits? Yes No
Personal App: Location Information
 
Occupancy Type
Protection Class
 

Style of Home (click for definitions)

 

 
Year Built
 

 
Construction Type
 

Foundation Type

Earthquake Fitted?
Storm Shutters? Yes No
 
 

Any portion of exterior constructed in Synthetic Stucco?

Yes No
 
Total Living Sq. Ft.
(Don't include basement sq ft)

 

 
Dwelling Type
Maintenance Condition
Inspection Date
 

 
Fire Protection District
 

 
Miles to Fire Dept.
 

 
Feet to Hydrant
 

 
Roof Type
Roof Update
Wiring Update
Heating System Type
Heating Update
Plumbing Update
Central A/C? Yes No
 
Burglar Alarm Type
Central Fire Alarm? Yes No
 
Sprinkler Type
 

You indicated this home contains sprinklers, please be sure to obtain proof in your agency file of this discount.


 
Combo - Dead Bolt Locks, Smoke Alarm & Fire Extinguisher Yes No
 
Controlled Access Community or Building? Yes No
 
 

Number of Full Baths


 

 
 

Number of 3/4 Baths


 

 
 

Number of Half Baths


 
 

To obtain a bindable quote, the Cost Guide Information will need to be completed. Do you want to complete the Cost Guide now?"

Yes No
 
Deductible
Wind Hail Deductible
Coverage I Dwelling
 

 
Dwelling Replacement Cost
 

 
Coverage II Other Structures
 

 
Coverage III Personal Property
 

 
Coverage IV Loss of Use
 

 
 

 
Coverage V Personal Liability
Coverage VI Medical Payments to Others
Personal Injury
 
Optional Coverages
 
Extended Dwelling Coverage
Unscheduled Jewelry
Unscheduled Silverware
 

 
Unscheduled Business Property
 

 
Increased Trees/Plants/Shrubs Yes No
 
Backup of Sewer/Drain/Sump-Pump
Ordinance or Law
Business Merchandise
 

 
Volunteer America
 

 
Landlord Furnishings
 

 
Business Use on Other Structures
 

 
In-Home Business
Incidential Farming Liability
Additional Residence occupied by Insured - # of Families
Theft of Building Materials Yes No
 
Increased Tool Theft
Increased Memorabilia, Souveniers, Collector's Items
Loss Settlement for Roofs - ACV for Wind & Hail (Policy provides Replacement Cost) Yes No
 
Loss Settlement for Roofs - ACV for All Perils (Policy provides Replacement Cost) Yes No
 
Building Property Loss Settlement?
Personal Property Loss Settlement?
Replacement Cost Loss Settlement Non-Building Structures
 
Coverage B Off Premises
 
Credit Card
 
Coverage C Increased Special Limits
 
Extended Theft Coverage for Premises Occasionally Rented
 
Foundation Coverage
 
Identity Fraud Expense Coverage
 
Incidental Low Power Recreational Motor Vehicle
 
Inflation Guard
 
Optional Mold Coverage
 
Other Members of Your Household
 
Other Structures Off Premises
 
Other Structures Rented to Others
 
Permitted Incidental Occupancy Other Residence
 
Permitted Incidental Occupancy Residence Premsies
 
Refrigerated Property
 
Residence Held in Trust
 
Sinkhole Collapse
 
Special Computer
 
Special Personal Property
 
Special Extensions of Coverage
 
Outboard Motor Liability
Business Liability
Business Pursuits Class
Worker's Comp - Inservants Yes No
 
Worker's Comp - Outservants Yes No
 
Loss Assessment
Home Day Care Yes No
 
Scheduled Personal Property
 
Scheduled Personal Property Items? Yes No